COVID-19 Screening Questionnaire
We all need to be committed to this – if you answer yes to any of the following questions, we ask that you re-schedule or call to discuss. We retain the right to refuse treatment if the declaration hasn’t been completed or if we feel there is a risk to staff or other clients.

Our staff are following the same guidelines for health and hygiene and we request that you do the same. This is to keep us all safe. Thank you
Email address *
IMPORTANT: Protocol for visiting the clinic.
When you come into the clinic for an appointment, we would appreciate, where possible, that you come alone, to enable us to maintain safe numbers in the waiting room. We do understand though if you need a support person with you. We will need their details for contact tracing, and they too will need to complete the above questionnaire.

You will need to bring appropriate clothing for your appointment as we are unable to provide shorts or gowns. Please also bring any exercise bands etc you may use for your exercises as we are unable to share any equipment such as this between patients
To ensure contact is minimised (especially in the Reception waiting area), the providers have increased the length of time between clients and they are staggering these times. This is also to provide time for cleaning surfaces between patients. Chairs have been spaced further apart and standing space will also be provided

We need you to use the hand sanitiser provided at the door when you enter the premises. You may be asked to confirm that you have done this.

Masks will be provided if necessary under MOH guidelines.

Thank you for your cooperation in keeping us all safe.

The Team At Te Aro Physiotherapy & Pilates
Covis - 19 Patient Questionnaire:
Please fill out the below question prior to your appointment.
Patient Name *
Your answer
Date of Birth *
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Today's Date *
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Please circle YES or NO to the following questions *
Yes
No
Have you or travelled outside of the Wellington region in the last 14 days?
Have you been in close contact with anyone who has travelled domestically or internationally in the last 14 days
Have you attended any events or gatherings of more than 10 people in the last 14 days?
Have you been in close contact with a person known to have the Covid-19 Virus?
Have you, or someone you have been in close contact with, been tested and are still awaiting results for COVID-19?
Have you or a close contact been asked to self-quarantine?
Do you or anyone you have been in close contact with, have any of the following: Fever or chills, Cough, Shortness of breath or difficulty breathing, Body aches, Headache, New loss of taste or smell or a Sore throat?
Are you over 70 or have compromised immune system?
Explain any YES answers in the box below:
Your answer
Signature: By typing your name in the box below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge: *
Your answer
Declaration Date *
MM
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DD
/
YYYY
Support Person Questionaire:
When you come into the clinic for an appointment, we would appreciate, where possible, that you come alone, to enable us to maintain safe numbers in the waiting room.

We do understand though if you need a support person with you. We will need their details for contact tracing, and they too will need to complete the below questionnaire.
Please circle YES or NO to the following questions
Yes
No
Have you or travelled outside of the Wellington region in the last 14 days?
Have you been in close contact with anyone who has travelled domestically or internationally in the last 14 days
Have you attended any events or gatherings of more than 10 people in the last 14 days?
Have you been in close contact with a person known to have the Covid-19 Virus?
Have you, or someone you have been in close contact with, been tested and are still awaiting results for COVID-19?
Have you or a close contact been asked to self-quarantine?
Do you or anyone you have been in close contact with, have any of the following: Fever or chills, Cough, Shortness of breath or difficulty breathing, Body aches, Headache, New loss of taste or smell or a Sore throat?
Are you over 70 or have compromised immune system?
Signature: By typing your name in the box below, you acknowledge that the answers you provided are true and accurate to the best of your knowledge:
Your answer
Declaration Date
MM
/
DD
/
YYYY
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